Custom form C No.5290-4
Reference No. Number of page
/ 1. Exporter’s Name, Address and Country:
2. Importer’s or Consignee’s Name, Address and Country:
3. Means of transport and route (as far as known):
Departure Date:
Port of Discharge:
AGREEMENT BETWEEN THE GOVERNMENT OF MALAYSIA AND THE GOVERNMENT OF JAPAN FOR AN ECONOMIC PARTNERSHIP
FORM MJEPA
Issued in _________________
(Country) See Notes Overleaf
4. Item Number (as necessary); Marks and Numbers; Number and kind of Packages;
Description of Good(s); HS Code; Other Instances
5. Preference Criterion
6. Quantity or Gross Weight, and FOB Value (Optional)
7. Invoice Number and Date
8. Remarks:
9. Declaration by the Exporter:
I, the undersigned, declare that:
- the above details and statement are true and accurate;
- the good(s) described above meet the condition(s) required for the issuance of this certificate;
- the country of origin of the good(s) described above is ________________________________________
Place and date: ______________________________
Signature: __________________________________
Name (printed): _____________________________
Company: __________________________________
10. Certification
The undersigned hereby certifies that the above-mentioned good(s) are considered originating.
Competent governmental authority or Designee office:
___________________________________________
Stamp
Place and date: _______________________________
Signature: ___________________________________
Countries which accept this form for the purpose of preferential treatment under the Agreement between the Government of Japan and the Government of Malaysia for an Economic Partnership (hereinafter referred to as “the Agreement”) are Japan and Malaysia.
General Condition:
The main condition for admission to the preferential tariff treatment under the Agreement is that the goods exported to Japan or Malaysia will:
i. fall within description of products eligible for concession in Japan or Malaysia.
ii. comply with one of the requirements set out in Preference Criteria ; and iii. comply with the consignment criteria of Article 32 of the Agreement .
Preference Criteria:
A The goods is wholly obtained or produced entirely in the territory of the Country, as defined in paragraph 2 of Article 28.
B The good is produced entirely in the territory of the Country exclusively from originating materials of the Country.
C The good satisfies the product specific rules set out in Annex 2, as well as all other applicable requirements of Chapter 3, when the good is produced entirely in the territory of the Country using non-originating materials.
Instructions for Certificate of Origin:
For the purposes of obtaining preferential tariff treatment, this document must be completed legibly and in full by the exporter or its authorised agent. Any item of the form must be completed in the English language. The certificate of origin will be no longer valid, if it is completed in any languages other than English or modified after the issuance.
If the space of this certificate is insufficient to specify the necessary particulars for identifying the goods and other related information, the exporter or its authorised agent may specify the information using additional Appendix 1-A.
Field 1: State the full name, address and country of the exporter.
Field 2: State the full name, address and country of the importer or consignee.
Field 3: Provide the name of loading port, transit port and discharging port and the name of vessel / flight number, as far as known.
Field 4: Provide item number (as necessary), marks and numbers, number and kind of packages and Harmonized System (HS) Code as amended on 1 January 2002 and description of each good consigned. The description should be sufficient to relate to the description of invoice and to HS description of the good.
For each good, indicate at the six-digit or a more detailed level of the HS tariff classification. If the goods is subject to a product specific rule in Annex 2 that requires a special description (e.g. igusa goods), indicate such description.
With respect to each good of Chapter 16 or 18 through 20 of the HS, the materials of third States which are member countries of the ASEAN and the names of such third States must be indicated (if such materials were used in the production of the good(s)).
With respect to each good of Chapter 19 or 20 of the HS, the materials harvested, picked or gathered in the territory of either Country or third States which are member countries of the ASEAN and the names of such Country or third States shall be indicated (if such materials were used in the production of the above mentioned materials used in the production of the good and classified in Chapter 7, 8, 11 or 17 of the HS).
With respect to each good of Chapter 50 through 63 of the HS, the materials of the other Country or third States which are member countries of the ASEAN, the processes or operations conducted in the territory of such Country or third States and the names of such Country or third States shall be indicated (if such materials were used in the production of the good).
Field 5: For each good, state which origin criterion (A through C under Preference Criteria above) is applicable. The rules of origin are contained in Chapter 3 and Annex 2.
Note: In order to be entitled to preferential tariff treatment, each good of a Country must meet at least one of the criteria given.
Indicate appropriately “ACU” for accumulation, “DMI” for De Minimis and “FGM” for fungible goods or materials.
Field 6: For each good, indicate the quantity or gross weight, and the FOB value (optional)
Field 7: Provide the invoice number and the date for each good. If the invoice is issued by a person different from the exporter or its authorised agent to whom the certificate of origin is issued and the person who issues the invoice is located in a third State, the number of invoice issued for the importation of goods into the territory of a Country shall be indicated, and in field 8 it should be indicated that the goods will be invoiced in a third State, identifying the full legal name and address of the person that issued the invoice.
If the number of invoice issued in the third States at the time of issuance of the certificate of origin is not known, the field should be left blank and the importer should provide the relevant authority of the importing Country with a sworn declaration that justifies the fact. In this declaration the importer should indicate, at least, the number of the invoice and the certificate used for the importation.
Field 8: If the certificate was issued retroactively, the issuing authority will indicate “ISSUED RETROACTIVELY”. If the certificate is reissued , the issuing authority will indicate the date of issuing and the reference number of the original certificate of origin. Other remarks as necessary.
Field 9: This field must be completed, signed and dated by the exporter or its authorised agents. The “Date” must be the date when the certificate is applied.
Note: The exporter’s or its authorised agent’s signature may be autographed or electronically printed.
Field 10:This field must be completed, dated, signed and stamped by the competent governmental authority or its designee of the exporting Country.
Note: The competent governmental authority’s or its designee’s signature may be autographed or electronically printed.
Notice 1. Any items entered in this form must be true and correct. False declaration or documents relating to the certificate of origin will be subject to penalty in accordance with the laws and regulations of the exporting Country.
Notice 2. The certificate of origin would be a basis of determination of origin at the relevant authority of the importing Country.
